Prior Authorization Program

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Prescription Drug List January 2011 Prior Authorization Program The prior authorization program helps us offer broad prescription drug coverage and promotes safe, clinically appropriate drug usage. Under the prior authorization program, certain drugs require approval. Your physician may call our Pharmacy Prior Authorization Department to request a medical necessity review. If you have any questions or concerns, please contact Member Services at the number listed on your ID card. This list is for informational purposes only and is subject to change. To confirm coverage, please contact your plan administrator or call the customer service number on your health plan ID card. Anemia Aranesp Darbepoetin Alfa Epogen Epoetin Alfa Procrit Epoetin Alfa Arthritis/Pain Conditions* Arthrotec* Diclofenac Sodium /Misoprostol (Generic products in this category Celebrex* Celecoxib do not require Prior Authorization) Flector* Diclofenac transdermal patch Mobic* Meloxicam Pennsaid* Diclofenac sodium topical solution Ponstel* Mefenamic Acid Prevacid Naprapac* Naproxen/Lansoprazole Voltaren gel* Diclofenac topical gel Arthritis/Related Inflammatory Conditions Actemra Tocilizumab Enbrel Etanercept Humira Adalimumab Kineret Anakinra Orencia Abatacept Rituxan Rituximab Simponi Golimumab Asthma Xolair Omalizumab Cancer Afinitor Everolimus Avastin Bevacizumab Firmagon Degarelix Gleevec Imatinib Mesylate Herceptin Trastuzumab Mylotarg Gemtuzumab Ozogamicin Nexavar Sorafenib Tosylate Novantrone Mitoxantrone Revlimid Lenalidomide Rituxan Rituximab Sprycel Dasatinib Sutent Sunitinib Malate Tarceva Erlotinib Tasigna Nilotinib Thalomid Thalidomide Treanda Bendamustine Hcl Tykerb Lapatinib Ditosylate Votrient Pazopanib Zolinza Vorinostat 827109 d 12/10 1 mycignaforhealth.com

Chemokine Receptor Mozobil Plerixafor CAPS Arcalyst Rilonacept Ilaris Canakinumab Crohn s Disease Cimzia Certolizumab Pegol Humira Crohn s Starter Pack Adalimumab Tysabri Natalizumab Dystonia and Spasticity Botox Botulinum Toxin A Dysport Abobotulinumtoxin A Myobloc Botulinum Toxin B Enzyme Deficiency Elaprase Idursulfase Growth Deficiency Genotropin Humatrope Increlex Mecasermin Rinfabate Norditropin Nutropin Nutropin AQ Nutropin Depot Omnitrope Saizen Serostim Tev-Tropin Growth Hormone Receptor Antagonists Somavert Pegvisomant Heartburn/Ulcer* Dexilant* Dexlansoprazole (Generic products in this category Prevacid* Lansoprazole do not require Prior Authorization) Prilosec* Omeprazole Prilosec Susp.* Omeprazole Protonix* Pantoprazole Zegerid* Omeprazole/sodium bicarbonate Hemophilia Advate Alphanate Alphanate/VWF Antihemophilic Factor/von Willebrand Factor complex (Human) AlphaNine SD Autoplex T Anti-inhibitor Coagulant Complex Bebulin VH BeneFix Factor IX Complex (Recombinant) Feiba VH Anti-inhibitor Coagulant Complex Helixate FS Hemofil M Humate-P Koate-DVI Kogenate FS Monarc-M Monoclate-P Mononine Factor IX (Purified/Human) NovoSeven Factor VIIa (Recombinant) Profilnine SD Proplex T Recombinate Hemophilia (continued) ReFacto 2

Wilate Antihemophilic Factor VIII Von Willibrand (Human) Xyntha Hepatitis Infergen Interferon Alfacon-1 Pegasys Peginterferon Alfa-2a Peg-Intron Peginterferon Alfa-2b Hyperlipidemia (high cholesterol)* Altoprev* Lovastatin, extended-release (Generic products in this category Crestor* Rosuvastatin do not require Prior Authorization) Livalo* Pitavastatin Mevacor* Lovastatin Pravachol* Pravastatin Zocor* Simvastatin Hypertension* Atacand* Candesartan/HCTZ Angiotensin II Avalide* Irbesartan/HCTZ Antagonists (ARBs) Azor* Olmesartan/Amlodipine Avapro* Irbesartan Benicar* Olmesartan Benicar HCT* Olmesartan/HCTZ Cozaar* Losartan Diovan* Valsartan Diovan HCT* Valsartan/HCTZ Exforge* Valsartan/Amlodipine Hyzaar* Losartan/HCTZ Micardis* Telmisartan Micardis HCT* Telmisartan/HCTZ Tekturna* Aliskiren Tekturna HCT* Aliskiren/HCTZ Teveten* Eprosartan Teveten HCT* Eprosartan/HCTZ Twynsta* Telmisartan/Amlodipine Valturna* Aliskiren/Valsartan Immune System Deficiency Carimune NF Flebogamma Gammagard Liquid Gammagard S/D Gamunex Hizentra Immune Globulin SQ Iveegam EN Octagam Polygam S/D Privigen Vivaglobin Immune Globulin SQ Infertility Bravelle Urofollitropin Cetrotide Cetrorelix Acetate Clomid Clomiphene Citrate Fertinex Urofollitropin Follistim AQ Follitropin Beta, Recombinant Ganirelix Acetate** Ganirelix Acetate Ganirelix Acetate/Follistim Ganirelix Acetate/Follitropin Beta Gonal-F Follitropin Alpha, Recombinant Luveris Lutropin Alfa Menopur Menotropin 3

Infertility (continued) Novarel Ovidrel Pregnyl Profasi Repronex Menotropin Serophene Clomiphene Citrate Insomnia* Ambien* Zolpidem, immediate release (Generic products in this category Ambien CR* Zolpidem do not require Prior Authorization) Edluar* Zolpidem SR Lunesta* Eszopiclone Rozerem* Ramelteon Sonata* Zaleplon ITP Nplate Romiplostim Promacta Eltrombopag Multiple Sclerosis Ampyra Dalfampridine Avonex Admin Pack Interferon Beta-1a Betaseron Interferon Beta-1b Copaxone Glatiramer Acetate Extavia Interferon Beta-1b Novantrone Mitoxantrone Rebif Interferon Beta-1a/Albumin Tysabri Natalizumab Narcolepsy Nuvigil Armodafinil Provigil Modafinil OB/Gyn 17-hydroxy-progesterone Hydroxyprogesterone Caproate USP PKU Kuvan Sapropterin Psoriasis Amevive Alefacept Enbrel Etanercept Humira Adalimumab Stelara Ustekinumab Pulmonary Hypertension Adcirca Tadalafil Flolan Epoprostenol Letairis Ambrisentan Remodulin Treprostinil Revatio, injection Sildenafil Citrate Tracleer Bosentan Ventavis Iloprost Respiratory Syncytial Virus (RSV) Synagis Palivizumab 4

- Therapeutic category Therapeutic drugs Actinic Keratosis Zyclara Imiquimod Angioedema Cinryze C1 Esterase inhibitor Kalbitor Ecallantide Diabetes Victoza Liraglutide Mucopolysaccharidosis VI Nagalazyme Galsulfase (Maroteaux-Lamy Syndrome) Neuropathic Pain Qutenza Topical Patch Capsaicin 8% topical patch Postherpetic Neuralgia (PHN) Pompe Disease Myozyme Alglucosidase alfa * Drug is part of the Step Therapy program only. Step Therapy is a prior authorization program designed for you and your doctor to take one step at a time when choosing your medication. It works to help you find the most affordable medication appropriate for your condition. ** Ganirelix Acetate injection was formerly called Antagon. This list is for informational purposes only and is subject to change. To confirm coverage, please contact Member Services at the phone number listed on your ID card. CIGNA and the Tree of Life logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries, including Connecticut General Life Insurance Company and CIGNA Health and Life Insurance Company, and not by CIGNA Corporation. 827109 d 12/10 2010 CIGNA. mycignaforhealth.com 5

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